The following is a list of the most commonly prescribed drugs. It represents an abbreviated version of the drug list (formulary) that is at the core of your prescription drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: Brand name drugs may move to nonformulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call Open Access (2021) the phone number printed on your member ID card.
A azithromycin clindamycin E gemfibrozil abirateroneQL, PA, † B clindamycin phosphate econazole nitrate GENOTROPINPA, † acetaminophen-codeine baclofen clindamycin-benzoyl ELIQUISQL gentamicin sulfate peroxideAE acyclovir benazepril ELMIRON GENVOYAQL, † clobetasol propionate adapalene-benzoyl benazepril-HCTZ EMGALITYQL, PA, † glatiramer acetateQL, PA, † peroxideAE clonazepam BETASERONQL, PA, † enalapril glimepiride ADVAIR DISKUSQL clonidine bisoprolol-HCTZ enalapril-HCTZ glipizide ADVAIR HFAQL clopidogrel bisulfate bosentanQL, PA, † ENBRELQL, PA, † glipizide ER AIMOVIGQL, PA, † clotrimazole BREO ELLIPTAQL Endometrin glipizide XL QL, PA, † AJOVY QL clotrimazole-betametha- AE QL BRILINTA sone EPIDUO FORTE GLUCAGON [INJ] albuterol HFAQL brimonidine tartrate colesevelamQL epinastine drops glyburide alendronate sodium QL QL bromfenac drops colestipol epinephrine [INJ] GLYXAMBI alfuzosin ER QL QL budesonide COMBIPATCHQL EPIPEN [INJ] guanfacine allopurinol QL QL buprenorphine-naloxone COMBIVENT RESPIMATQL erythromycin guanfacine ER alprazolam bupropion PA, † escitalopram oxalate H QL, PA, † COSENTYX ambrisentan PA, † bupropion ER (smoking CREON esomeprazole magne- HUMIRA amiodarone deterrent)QL siumQL, ST cyanocobalamin [INJ] hydralazine AMITIZAQL, PA bupropion ER (SR) estradiol cyclobenzaprine hydrochlorothiazide amitriptyline bupropion ER (XL) eszopicloneQL, ST cyproheptadine hydrocodone- acetamino- amlodipine buspirone etodolac phen D amlodipine-benazeprilST butalbital-apap-caffeineQL EUFLEXXAQL, PA, † hydrocodone-ibuprofen dalfampridine ERQL, PA, † amoxicillin butalbital-asa-caffeineQL exemestane hydrocortisone deferasiroxPA, † amoxicillin-clavulanate BYSTOLICQL, ST ezetimibeQL, ST hydromorphone DESCOVYQL, † amphetamine- C F hydromorphone ERQL dextroamphetamineAE desloratadineQL cabergoline FARXIGAQL hydroxychloroquine sulfate amphetamineQL,AE, ST dexamethasone calcitriol febuxostat hydroxyzine anastrozole diazepam carbamazepine fenofibrate micronizedQL hyoscyamine sulfate ANORO ELLIPTAQL diclofenac sodium carbidopa-levodopa finasteride I aprepitantQL dicyclomine carvedilol FLOVENT DISKUSQL ibandronate sodiumQL, PA,† aripiprazoleQL digoxin cefadroxil FLOVENT HFAQL imatinib mesylateQL, PA, † armodafinilQL, PA diltiazem ER cefdinir fluconazole IMBRUVICAQL, PA, † ARMOUR THYROID dimethyl fumarateQL, PA, † cefuroxime axetil fludrocortisone acetate indomethacin ARNUITY ELLIPTAQL diphenoxylate-atropine celecoxibQL fluorometholone ipratropium bromide ASMANEX HFAQL divalproex cephalexin fluorouracil† ipratropium-albuterol atenolol divalproex ER CEREZYMEPA, † fluoxetine irbesartan atenolol-chlorthalidone dorzolamide-timolol CETROTIDEPA, † fluvoxamine isosorbide mononitrate ER atorvastatin doxazosin mesylate CHANTIXQL folic acid isotretinoinAE ATRIPLAQL, † doxepin chlorhexidine gluconate FORTEOQL, PA, † J ATROVENT HFAQL doxycycline hyclate ciclopirox FULPHILAQL, PA, † JANUMET XRQL AUBAGIOQL, PA, † doxycycline monohydrate cinacalcetPA, † furosemide JANUMETQL azathioprine DUAVEEQL ciprofloxacin G JANUVIAQL azelaic acidAE duloxetineQL ciprofoxacin-dexametha- gabapentin JARDIANCEQL azelastine sone drops DUPIXENTQL, PA, † GAMMAGARDPA, † azelastine drops citalopramQL dutasterideQL GAMUNEX-CPA, † azelastine-fluticasoneQL clarithromycin (continued)
THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 1/1/2021. THIS LIST IS SUBJECT TO CHANGE.
WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC. K methylprednisolone oxcarbazepine REMICADEPA, † tizanidineQL ST ketoconazole metoclopramide oxybutynin REPATHAQL, PA, † tobramycin ketorolac drops metoprolol succinate ER oxybutynin ER RESTASISQL, PA tobramycin-dexamethasone ketorolac tromethamine metoprolol tartrate oxycodone REVLIMIDQL, PA, † tolterodine tartrate KOVALTRY† metronidazole oxycodone-acetamino- RINVOQQL, PA, † topiramate phenQL L MINIVELLEQL risperidone TOUJEO OXYCONTINQL labetalol minocycline ritonavirQL, † tramadol oxymorphone ERQL lactulose mirtazapine rizatriptan benzoateQL tramadol-acetaminophen OZEMPICQL, PA lamotrigine misoprostol ropinirole TRAVATAN ZST P lansoprazole modafinilQL, PA ropinirole ERQL ST trazodone pantoprazole LANTUS mometasone furoate rosuvastatin calciumQL, ST TREMFYAQL, PA, † paroxetine latanoprost MONOVISCQL, PA, † RUZURGIQL, PA, † TRESIBA QL ST peg-3350 electrolyte LATUDA montelukast solution S triamcinolone acetonide QL leflunomide morphine sulfate ER penicillin v potassium sertraline triamterene-HCTZ QL, PA letrozole MOVANTIK PENTASA sevelamer carbonate triazolam QL, † LEVEMIR mupirocin permethrin silodosin TRIUMEQ QL, PA levetiracetam mycophenolate mofetil phenazopyridine simvastatin TRULICITY QL, ST QL, PA, † QL, † levocetirizine MYRBETRIQ phenytoin SKYRIZI TRUVADA levofloxacin N pimecrolimus sodium fluoride V levothyroxine nabumetone pioglitazone sodium sulfacetamide valacyclovir QL QL,ST lidocaine viscous naltrexone polymyxin b-trimethoprim solifenacin succinate valsartan QL, PA LINZESS naproxen posaconazolePA sotalol valsartan-HCTZ QL QL QL, PA, † liothyronine naratriptan potassium chloride ER SPIRIVA HANDIHALER VENCLEXTA lisinopril neomycin-polymyxin- potassium citrate ER spironolactone venlafaxine hydrocortisone lithium SPRYCELQL, PA, † venlafaxine ER PA,† pravastatin NEUPOGEN [INJ] PA, † lithium ER prazosin STELARA verapamil ER QL, ST nifedipine ER QL QL, PA LIVALO prednisolone STIOLTO RESPIMAT VICTOZA nitrofurantoin QL QL, ST LO LOESTRIN FE prednisone SUBOXONE VIIBRYD nitroglycerin QL lorazepam pregabalinQL, ST sucralfate VIMPAT nortriptyline QL, † losartan potassium QL sulfamethoxazole- VIREAD † PREMARIN NOVOEIGHT trimethoprim PA, † losartan potassium-HCTZ PREMPROQL VIVITROL NOVOLIN 70/30 sulfasalazine QL, AE, ST loteprednol etabonate PREPOPIK VYVANSE NOVOLIN N sumatriptanQL lovastatin W prochlorperazine QL ST NOVOLIN R [INJ] SYMBICORT LUMIGAN progesterone warfarin NOVOLOG SYNJARDYQL M promethazine X-Y QL, PA, † NOVOLOG FLEXPEN SYNTHROID QL MAVYRET promethazine-codeine XARELTO NUCALAPA, † T-U MAYZENTQL, LD, PA, † XEMBIFYPA, † QL promethazine-DM NUVARING tacrolimus QL, PA meclizine propranolol XIFAXAN nystatin tadalafil (PAH)QL, PA, † medroxyprogesteroneQL XIIDRAQL, PA propranolol ER QL ST O tadalafil PA, † meloxicam QL XOLAIR QL, ST PULMICORT FLEXHALER QL olmesartan medoxomil tamoxifen citrate QL memantine pyridostigmine XULTOPHY olmesartan-HCTZQL, ST tamsulosin mercaptopurine Q Z QL olopatadine temazepam mesalamine quetiapine ERQL ST zaleplon omega-3-acid ethyl estersQL tenofovir disoproxil metformin quetiapineQL fumarateQL, † ZENPEP ondansetron metformin ERQL ZIEXTENZOQL, PA, † QL quinapril terbinafine ONETOUCH QL, ST methadone QL zolpidem ER PA, † QVAR REDIHALER terconazole OPDIVO QL methimazole R testosterone cypionate zolpidem ORILISSAQL, PA, † methocarbamol ramipril testosteronePA zonisamide ORTHOVISCQL, PA, † methotrexate QL QL ranolazine ER timolol maleate QL, AE oseltamivir methylphenidate ER REBIFQL, PA, † TIVICAYQL, † OTEZLAQL, PA, † methylphenidateQL, AE (continued)
THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 1/1/2021. THIS LIST IS SUBJECT TO CHANGE.
WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC. Examples of Non-Preferred Medications with Selected Formulary Alternatives The following is a list of some non-preferred brand-name medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.
Non-Preferred Medication(s) Selected Preferred Alternative(s)
ACANYAPA and ONEXTONPA (clindamycin phosphate-benzoyl peroxide) clindamycin and benzoyl peroxide (separate agents) ADMELOGPA (insulin lispro) NOVOLOG ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT AEROSPANPA (flunisolide) DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL AIRDUOPA QL(fluticasone-salmeterol 55-14 mcg, 113-14 mcg, 232-14 mcg) ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL ALLZITALPA QL (butalbital-acetaminophen 25-325 mg) and butalbital-acetaminophen butalbital-acetaminophen 50-325 mgQL 50-300 mgPA QL ALPHAGAN-P (brimonidine) brimonidine 0.15% ARNUITY ELLIPTAQL, ASMANEX HFAQL, ASMANEX TWISTHALERQL, FLOVENT ALVESCO PA (ciclesonide) DISKUSQL, FLOVENT HFAQL, PULMICORT FLEXHALERQL, QVAR REDIHALERQL AMRIXPA QL (cyclobenzaprine ER) cyclobenzaprine 5 mg, cyclobenzaprine 10 mg APIDRAPA (insulin glulisine) NOVOLOG APIDRA SOLOSTARPA (insulin glulisine) NOVOLOG AUVI-QPA QL (epinephrine solution) epinephrine 0.15 mgQL, epinephrine 0.3 mgQL, EPIPENQL, EPIPEN JRQL BASAGLARPA (insulin glargine) LANTUS, LEVEMIR, TOUJEO, TRESIBA BELSOMRAPA QL (suvorexant) zolpidem IRQL, zaleplon BONJESTAPA QL and DICLEGISPA QL (doxylamine-pyridoxine) OTC doxylamine and OTC pyridoxine BRAVELLE† PA (urofollitropin) GONAL-F†, GONAL-F RFF† BYETTAPA QL (exenatide) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL BYDUREONPA QL (exenatide extended-release) OZEMPICPA QL, TRULICITYPA QL, VICTOZAPA QL CALQUENCEQL, PA, †(acalabrutinib) IMBRUVICAQL, PA, †, VENCLEXTAQL, PA, † CETRAXALPA QL (ciprofloxacin 0.2% otic soln) ofloxacin otic soln COMBIGAN (brimonidine-timolol) brimonidine 0.2% and timolol 0.5% (separate agents) CRINONE(progesterone gel) medroxyprogesterone, norethindrone, progesterone, Endometrin DENAVIRPA (penciclovir) acyclovir ointment DEXILANTQL (dexlansoprazole) lansoprazole, omeprazole, pantoprazole DIABETES TEST STRIPSPA QL (e.g., Accu-Chek, Ascensia, Breeze, Contour, etc.) ONETOUCHQL DUEXISPA QL (famotidine-ibuprofen) OTC famotidine and OTC ibuprofen (separate agents) DULERAPA QL (mometasone-formoterol) ADVAIR DISKUSQL, ADVAIR HFAQL, BREO ELLIPTAQL, SYMBICORTQL DUREZOLPA (difluprednate) prednisolone acetate ophth solution EXTAVIA† PA QL BETASERON† PA QL, REBIF† PA QL FOLLISTIM AQ† PA (follitropin beta) GONAL-F†, GONAL-F RFF† FORFIVO XLPA QL (bupropion ER) bupropion ER GLUMETZAPA QL and FORTAMETPA QL (metformin ER modified/osmotic) metformin ER (generic Glucophage XR) GRALISEPA QL (gabapentin) gabapentin HIZENTRAPA, †(immune globulin) GAMMAGARDPA, †, GAMUNEX-CPA, †, XEMBIFYPA, † HORIZANTPA QL (gabapentin ER) gabapentin HUMALOGPA (insulin lispro) NOVOLOG HUMULIN NPA (insulin isophane), HUMULIN RPA (insulin regular), HUMULIN NOVOLIN N, NOVOLIN R, NOVOLIN 70/30 70/30PA (insulin NPH and regular) ILEVRO (nepafenac) bromfenac drops, diclofenac drops, ketorolac drops INCRUSE ELLIPTAPA (umeclidinium) SPIRIVAQL INVOKANAPA QL (canagliflozin) FARXIGAQL, JARDIANCEQL INVOKAMETPA QL (canagliflozin-metformin), INVOKAMET XRPA QL SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL (canagliflozin-metformin ER) JENTADUETOPA QL,JENTADUETO XRPA QL (linagliptin and metformin) JANUMETQL, JANUMET XRQL JUBLIAPA (eficonazole) ciclopirox KAZANOPA QL (alogliptin-metformin) JANUMETQL, JANUMET XRQL KOMBIGLYZE XRPA QL (saxagliptin-metformin ER) JANUMETQL, JANUMET XRQL LASTACAFTPA QL (alcaftadine eye soln) OTC ketotifen eye soln (continued)
THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 1/1/2021. THIS LIST IS SUBJECT TO CHANGE.
WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC. Examples of Non-Preferred Medications with Selected Formulary Alternatives The following is a list of some non-preferred brand-name medications with examples of selected covered formulary alternatives. This is not an all-inclusive list.
Non-Preferred Medication(s) Selected Preferred Alternative(s)
NASCOBALPA (cyanocobalamin nasal) OTC vitamin B12 NESINAPA QL (alogliptin) JANUVIAQL NORDITROPIN†, PA (somatropin) GENOTROPIN†, PA NUCYNTA (tapentadol) hydrocodone-acetaminophen, morphine sulfate, oxycodone, tramadol NUCYNTA ER (tapentadol ER) hydromorphne ERQL, morphine sulfate ERQL, oxymorphone ERQL NEULASTA (pegfilgrastim) FULPHILAPA, QL, †, ZIEXTENZOPA, QL, † ONGLYZAPA QL (saxagliptin) JANUVIAQL OSENIPA QL (alogliptin-pioglitazone) JANUVIAQL and pioglitazone PANCREAZEPA (pancrelipase DR) CREON, ZENPEP PAZEO (olopatadine) azelastine drops, cromolyn drops, epinastine drops, ketotifen drops PERTZYEPA (pancrelipase DR) CREON, ZENPEP PRIVIGENPA, † (immune globulin) GAMMAGARDPA, †, GAMUNEX-CPA, †, XEMBIFYPA, † PROAIRQL, PROAIR RESPICLICKQL (albuterol sulfate) albuterol HFAQL PROVENTIL HFAPA QL (albuterol) albuterol HFAQL QTERNPA QL (dapagliflozin-saxagliptin) GLYXAMBIQL SEGLUROMETPA QL (ertugliflozin-metformin) SYNJARDYQL, SYNJARDY XRQL, XIGDUO XRQL STEGLATROPA QL (ertugliflozin) FARXIGAQL, JARDIANCEQL STEGLUJANPA QL (ertugliflozin-sitagliptin) GLYXAMBIQL SOLARAZEPA (diclofenac 3% gel) Fluorouracil 5% cream SOLIQUAPA QL (insulin glargine-lixisenatide) XULTOPHYPA QL SOLODYNPA QL (minocycline ER) minocycline SOOLANTRAPA (ivermectin cream) metronidazole cream TIROSINTPA QL (levothyroxine) levothyroxine, SYNTHROID TRADJENTAPA QL (linagliptin) JANUVIAQL TREXIMETPA QL (sumatriptan-naproxen) sumatriptanQL and naproxen (separate agents) TUDORZA PRESSAIRPA QL (aclidinium) SPIRIVAQL UDENYCA (pegfilgrastim-cbqv) FULPHILAPA, QL, †, ZIEXTENZOPA, QL, † VENTOLIN HFAPA QL (albuterol sulfate) albuterol HFAQL VIMOVOPA QL (esomeprazole-naproxen) OTC esomeprazole and OTC naproxen XOPENEX HFAPA QL (levalbuterol) albuterol HFAQL ZEGERIDPA QL (omeprazole-sodium bicarbonate) OTC omeprazole-sodium bicarbonate ZIANAPA and VELTINPA (clindamycin phosphate-tretinoin) clindamycin and tretinoinAE (separate agents) ZIOPTANPA QL (tafluprost) latanoprost ZORVOLEXPA QL (diclofenac) diclofenac sodium DR ZOVIRAX CREAMPA acyclovir ointment ZYFLOPA QL (zileuton) and ZYFLO CRPA QL (zileuton ER) montelukast, zafirlukast
KEY For the member: Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the US Food and Drug Administration (FDA) may not be [INJ] = Injectable Drug covered upon release to market. ER = Extended-Release WellDyne may contact your provider after receiving a prescription to request consideration of a drug list product or generic DR = Delayed Release equivalent. This may result in your provider prescribing, when medically appropriate, a different brand-name product or generic
AE = Age Edit equivalent in place of the original prescription. Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. LD= Limited Distribution In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-pre- PA = Prior Authorization ferred or excluded option upon release of the generic product to the market. QL = Quantity Limits For the physician: Generics should be considered the first-line of prescribing. Please prescribe preferred products and allow generic ST = Step Therapy substitutions when medically appropriate. Brand-name drugs are listed in CAPITAL letters; generic drugs are listed in lower case letters.
† Indicates specialty medications This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to market.
THIS DOCUMENT LIST IS EFFECTIVE 1/1/2021 THROUGH 12/31/2021. UPDATED ON 1/1/2021. THIS LIST IS SUBJECT TO CHANGE.
WellDyne.com ©2021. WellDyne® is a servicemark of WellDyneRx, LLC.